Inspection·May 10, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58). Residents Affected - Some Findings include: Review of Resident 10's clinical records revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. The resident had an order for IV (Intravenous- a medication administered through a needle or tube inserted into a vein) antibiotics. Observation conducted on March 7, 2024, at 11:00 a.m., revealed a central line catheter to Resident 10's right upper chest. Observation conducted of Resident 10's room on the first three days of the survey failed to reveal evidence of EBP (Enhanced Barrier Precautions) signage or PPE (Personal Protective Equipment). Observation conducted on May 10, 2024, at 11:01 a.m., revealed Resident 21 had a pressure ulcer to the sacrum. Continued observation revealed resident had an indwelling foley catheter (flexible tube inserted into the bladder for removing fluid). An observation of Resident 21's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 50's clinical record revealed diagnosis list includes a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 56's clinical record revealed diagnosis list including but not limited to Gastrostomy Tube. Observation conducted of Resident 56's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 58's clinical records revealed the resident had an indwelling Foley catheter. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395974 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monticello House 1048 W Baltimore Avenue Media, PA 19063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)